IN THE PUSH FOR TRANS PRICE AND QUALITY COME TO A HEAD
Experts argue that to achieve true transparency in healthcare, price and quality data must be presented together so consumers can understand the value of services
“You get what you pay for.” Shoppers often use that phrase to gauge the value of goods in the economy. And—for the most part—it holds true. Consumers can usually expect a better product or service if they dish out more money. Except, that is, in healthcare.
In fact, those six words have little meaning in the sector that accounts for 18% of the U.S. economy, experts say. What actually determines prices in healthcare isn’t the quality of services at all, but competition—or lack thereof—in regional markets.
A large body of evidence has emerged during the past 20 years demonstrating that wide price variations exist among providers just miles apart. Hospitals and physician practices that dominate a region—or simply have an impressive reputation in the community—can leverage their clout with insurers and raise the price of services even if they perform on par with their lesser-known rivals down the road, said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.
For example, a study published in the May 2017 issue of Health Affairs found that patient experiences at high-priced and low-priced physician practices didn’t differ much. Patients at both the high-priced and lowpriced practices reported similar overall experiences of care, timely access to services and interactions with a primary-care physician.
“It’s about leverage. In a sense, that is probably a key reason for variation in pricing. It’s that some providers have much more leverage based on their reputation or their location, and they will be able to command higher prices because of that.” Paul Ginsburg Director of the Center for Health Policy Brookings Institution
The authors noted that competition, not quality of services, was the biggest driver of price differences.
Ginsburg agrees. “It’s about leverage. In a sense, that is probably a key reason for variation in pricing. It’s that some providers have much more leverage based on their reputation or their location, and they will be able to command higher prices because of that,” he said.
The convoluted relationship that exists between price and quality in healthcare is magnified in the push for greater transparency. To make it work, price and quality information must be presented together so consumers can understand the value of services.
“When we think about patients and consumers making healthcare decisions, we want people to choose the highest-value care for themselves,” said Anna Sinaiko, an assistant professor of health economics and policy at the Harvard School of Public Health. “In the absence of quality information, we might think more expensive care is better quality.”
Seeking consensus
The healthcare industry has made efforts for nearly 30 years to define and measure quality in healthcare, yet there still isn’t a standardized agreement among stakeholders around what quality care actually is and what it should look like, said Francois de Brantes, vice president and director of the Center for Payment Innovation at the not-for-profit Altarum Institute.
The CMS, accrediting bodies, healthcare improvement companies, not-for-profit organizations, providers and payers all measure quality in different ways.
Yet there are efforts underway in the industry to standardize quality measurement, said Dr. Don Goldmann, chief medical and scientific officer at the Institute for Healthcare Improvement. The push to value-based care has encouraged providers, payers and the government to examine ways to develop common measures across the industry as reimbursement is more closely tied to performance.
The CMS has established a basis for quality measurement through its reimbursement models and star ratings that weigh quality metrics to get a composite score, but not without disagreements and controversy. The American Hospital Association came out against the star ratings in a July 2016 letter to the CMS questioning the methodology and whether or not they “provide accurate and meaningful information to patients.”
Because there is little standardization in the industry around quality measurement, those who create these tools, including providers, payers and state officials, face the hard task of deciding what quality metrics to include and from what sources, Harvard’s Sinaiko said.
“It just remains really hard to measure quality in a meaningful way,” said Andrew Ryan, associate professor of health management and policy at the University of Michigan.
Consumers also just aren’t that concerned about quality-of-care information. The information they are really after is price data as they take on a larger share of health- care costs, said Judith Hibbard, research professor at the University of Oregon.
Nonetheless, people ultimately need to understand that quality differences exist between providers, Hibbard said.
Keeping it simple
The best way to communicate quality data on consumer-focused cost-comparison websites is to make it easy to understand, Hibbard said. Technical terms such as readmission or mortality rates hold little value to healthcare consumers. Studies have even shown that too much data and information can confuse people more.
It’s best to combine quality metrics to get an average score demonstrated through stars, ribbons, colors or check marks, Hibbard said. The CMS star-rating system is an example of this, although there are doubts that patients use the tool or even know it exists.
Consumers are much more receptive to recommendations from doctors, family and friends. Patients tend to lean toward these sources of information rather than clinical data because they highlight more interpersonal aspects of care that appeal to them, Hibbard said.
A recent study from not-for-profit organization Public Agenda found 68% of people recently diagnosed with Type 2 diabetes and 72% of women who recently gave birth reported that various interpersonal qualities of providers—for example, if the staff was respectful and the doctor took the time to answer questions—were very important factors when deeming care to be high quality. Conversely, only 41% of those with Type 2 diabetes and 43% of women who recently gave birth reported that various clinical qualities of doctors—such as whether the doctor had a high rate of patients whose blood sugar was under control—were very important to high-quality care.
This consumer interest for more interpersonal details of care delivery has greatly contributed to the popularity of patient reviews, said Jean-Pierre Stephan, a managing director at consulting firm Accenture. Reviews often read like personal narratives where authors explain their experiences with their healthcare providers.
A 2015 survey from Accenture found that 79% of healthcare consumers have read patient reviews. Con-
sumers’ most popular source for reviews—45%—was from their health plans. Provider websites ranked second at 28%, and the review website Healthgrades ranked third at 27%.
Patient reviews can even advance transparency in the industry because they hold providers and doctors accountable for what’s perceived as quality care. Reviews can give valuable feedback to providers on how to improve care and where they fall short, said Dr. Naomi Bardach, associate professor of pediatrics and health policy at the University of California at San Francisco.
Bardach and her colleagues showed the value of patient reviews in their study that found Yelp posts of hospitals corresponded strongly to results from the Hospital Consumer Assessment of Healthcare Providers and Systems, commonly known as HCAHPS.
For more than 20 years the Agency for Healthcare Research and Quality has touted the importance of patients’ feedback to improve quality of care and the patient experience through its various Consumer Assessment of Healthcare Providers and Systems surveys. “The patient is the best source of quality information and sometimes the only source of quality information,” said Caren Ginsberg, director of the CAHPS division at AHRQ.
The ratings game
Although online patient reviews can be beneficial for consumers, they are not without controversy. The sites are often criticized by doctors for their small sample sizes and tendency to attract mainly angry patients. Yelp has tried to address these concerns by adding CMS quality data such as emergency room wait times for hospitals. Most recently, the company announced it added cesarean-section rates at California hospitals through a partnership with the California Health Care Foundation.
Some hospitals have taken the issue into their own hands. University of Utah Health, for example, in 2012 took the then-bold step to post patient experience survey results online after physicians expressed distaste for negative reviews written about them on sites such as WebMD.
Physicians were concerned that these online reviews didn’t accurately represent the care they delivered. “The physicians really charged us to do something about it,” said Mari Ransco, manager for strategic initiatives at the health system.
The system decided that its large arsenal of patient experience surveys would present a much more accurate representation of the care their physicians provide rather than a few—often negative—reviews online.
When the system initially told physicians of the plan to publicly post their patients’ surveys on its website, they weren’t exactly open to the idea. Ransco said doctors were concerned that if their interactions with patients were broadcast online, their relationships with patients could be disrupted. Others were worried that a particularly bad interaction with a patient might end up online.
Ransco said a lot of time went into sitting down with physicians to let them know this “was the right thing to do.”
A patient experience survey, administered by Press Ganey, is emailed to all University of Utah Health patients within three business days after their outpatient appointment. A staff of four in the patient experience department read roughly 2,000 patient comments a week. All the surveys and reviews are posted online unless they have obscene language or breach patient privacy protections.
A physician profi le with reviews also isn’t established until the doctor has at least 30 reviews submitted by his or her patients to generate a large enough sample size. Roughly 17% of patients complete a survey.
Five years after the initiative began, physicians now generally like that their reviews are online, Ransco said. It has also inspired roughly 100 other hospitals to follow the health system’s lead, she added.
The fact that University of Utah doctors were motivated to improve as the result of transparency isn’t surprising, experts say. Transparency often leads to improvement because there is a pressure from the public to do better, said Anne Weiss, managing director at the Robert Wood Johnson Foundation.
“Transparency will lead to the kind of accountability that benefits everyone,” Weiss said.